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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

High Anxiety: The Supreme Court Ruling and the Future of Health Care

I told my husband yesterday morning that he needed to walk the dog. I had to listen to the news and be on my computer to follow SCOTUSblog, a live blog covering the US Supreme Court. I’ve never been so anxious about a pending Supreme Court ruling as I was about the one the Court made yesterday on the Affordable Care Act (ACA).

Diana Mason, PhD, RN

This past week, I talked with many of my health care colleagues, and while we all view the ACA as an important first step in transforming health care in the United States, many of them had a doom-and-gloom attitude. Recent court rulings had shown a conservative slant that didn’t bode well for the ACA.

So I actually cheered when I heard the ruling. But let’s be clear: the ACA is not a perfect law. No law is. Much work remains to be done, including addressing the following key issues:

  • The law will extend insurance coverage to about 30 million of the uninsured, leaving almost 20 million people still without coverage. While 22% of the remaining uninsured will be undocumented immigrants,  "40% would be eligible for, but not enrolled in, Medicaid or the Children’s Health Insurance Program (CHIP)", according to the Robert Wood Johnson Foundation.

  • We need an overhaul of our payment infrastructures. Although there are demonstration and pilot projects to reform care delivery and payment mechanisms, our struggling economy and comparatively poor health outcomes underscore the need for swift construction of reimbursement systems that reward wellness initiatives, better chronic care management, and more efficient and patient-centered acute care. Demonstrations in transitional care are underway. We’re eagerly awaiting the early reports of outcomes from the Accountable Care Organizations and the expansion of programs for keeping older adults in their own homes instead of nursing homes.

  • We’re still figuring out how to better manage the care of “dual eligibles”—those who qualify for both Medicare and Medicaid. These are the poorest and sickest patients that physicians, nurses, and other health care professionals care for. And they are the costliest.

  • The health care workforce is in transition. ACA monies and even private funds are supporting the development of a workforce that can expand primary care capacity and build interprofessional teams skilled in care coordination.

But focusing on these issues assumes that the fight about the ACA is over. It’s not. Within an hour of the Supreme Court ruling, House Speaker John Boehner issued a statement saying that the House GOP would vote to repeal the law: “Today’s ruling underscores the urgency of repealing this harmful law in its entirety.” And CNN reported Senate Minority Leader Mitch McConnell as saying, “Today’s decision makes one thing clear: Congress must act to repeal this misguided law…. Today’s decision does nothing to diminish the fact that Obamacare’s mandates, tax hikes, and Medicare cuts should be repealed and replaced with common sense reforms that lower costs and that the American people actually want.” And, as I was writing this post, presidential candidate Mitt Romney was on the radio and television saying that if elected he will push to repeal the ACA as one of his first acts as president.

Last week, I called a New York City medical center to pay a $500 bill for blood analyses for a young member of my extended family in his mid 30s. He had been working at a union job and was delighted to acquire health insurance after 6 months of full-time work. He went for his first primary care visit in more than 15 years. The physician asked him if he had insurance and the young man proudly said he did. What both didn’t know was that his policy had a $1000 deductible that he couldn’t pay. And he recently moved and no longer has insurance. The physician’s bill for that visit was more than $500.

I told the billing person that I was paying my family member’s bill and why. The woman replied with either deep empathy or excellent customer service training by saying, “I’m so sorry that he doesn’t have insurance.”

She gave me a discount, but I thought about those who don’t have someone else to cover their health care debts. I thought about the waste of her time and mine in trying to arrange to make some payment for the services rendered. And I thought about my family member, who now has a chance to get coverage because of the ACA.

I’m truly heartened by the Court’s ruling and my anxiety has dissipated. But I still feel an underlying tremor about our country’s ability to build on the foundation laid by the ACA.

About the author: Diana Mason, PhD, RN, is the Rudin Professor of Nursing and Co-Director of the Center for Health, Media, and Policy at the Hunter College, City University of New York, and President-elect of the American Academy of Nursing.
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